Tuesday, August 17, 2010

Eight years ago today...

Eight years ago my first son was born. It was the single most life-altering event in my life: I became a mother, but I also became scarred and took the first step on my journey toward birth activism. I almost never share my c-section birth story. It is incomplete, it makes me cry (not in a good way), it doesn't even get to the good part: hearing my son's first cry and hearing the OB announce that he is a boy. But here it is:

Little Vincente, you are everything I could have asked for. My love for you is total and complete, and I know without a doubt I would lay down my life for you. Your every breath, every yawn, every cry, is a joy to me. When I see you smile, my heart could burst from the love I feel for you. This is your birth story.

I found out I was pregnant on December 1, 2001. Your dad was out picking up wings at Woody’s when I took the pregnancy test, and when I saw that it was positive, I was so happy I jumped around the bedroom for a while. I think your dad was a little surprised, but he was happy, too. The pregnancy was easy. I didn’t have morning sickness, didn’t have weird cravings, didn’t gain too much weight (even though I did get HUGE). Feeling you kicking and squirming inside me was one of the most incredible sensations I’ve ever had. I remember the first time you got the hiccups, and also how when you’d get them right before you were born I could watch my belly jump a little with each one. Toward the end we realized you were going to be a big baby, and also that you were stubborn and didn’t want to come out. Induction was scheduled for August 15, a week past your due date.

Your father and I had gone to birth classes and were planning on having a natural, intervention-free birth. Since I didn’t go into labor naturally, we knew we were going to have to modify that plan somewhat, but were still hoping to have an essentially natural birth. The night of the 15th, we went to the hospital and checked ourselves in. The nurses started cervical ripening at about 11 p.m., and within a couple hours I was starting to feel some mild contractions. Labor! I thought. By the morning of the 16th, I was established in a pretty good contraction pattern, and my doctor broke my water. That picked the contractions up even more, and the labor nurse said we might not have to start pitocin as long as I was making progress. My mom showed up with Gary, and both of them came into the labor room—this was after I had said I didn’t want anyone in the labor room except your father and my mom. The labor nurse helped out by having me get into the Jacuzzi for a while, and wow was that wonderful. Unfortunately it also seemed to slow down my contractions, and when I got back to the room we had to start pitocin. Once the drip was started, I had to be hooked up to the monitors all the time, so I was restricted to the area right around my bed. That wasn’t too bad at first. Contractions were just starting to get painful, but since I could still change position and move around I was able to deal with it pretty well. Then the downward spiral began. Your heart rate started dropping after contractions, which concerned the hospital staff (and us, too). I had stopped making progress, so the pitocin had to be increased, which made your heart rate drop even more. By about 2:00 Saturday afternoon, the only position you would tolerate was me lying on my left side. Since I was stuck in bed, I couldn’t do anything for myself to help control the pain. I was tired and scared and frustrated and hurting, and I felt kind of alone. The birth wasn’t going like I had hoped, and I still wasn’t any closer to actually giving birth. It seemed like an awful lot of pain for no progress, and I was questioning my resolve to go drug-free. At some point your dad’s mom and your uncle Carlos came into the room, and I found myself thinking “Good lord, could you just keep everybody the f*** out of here???” My mom and Gary left to get lunch, and it was shortly after that I hit the lowest point in my labor. Your father was watching football, eating potato chips, while I lay in bed behind him, hurting and wishing he would come hold my hand or touch my face or just look at me and tell me I was doing good (even though I felt like I was a total failure at that point). Of course I didn’t say anything. Then mom and Gary got back with lunch, and your dad got up and walked out of the room without so much as a backward glance in my direction. After about 30 seconds in the room, alone, I started crying and totally lost the last of my ability to deal with the pain of the contractions. My mom came back to sit with me while your dad ate his lunch (I wasn’t allowed to eat or drink through this whole ordeal), and she and the nurses both kept asking me why I was crying. I couldn’t tell them it was because I wanted my husband to comfort me. I don’t know why I couldn’t tell them that, but I just couldn’t. So I said it was part pain, part concern for the baby, and part disappointment that the labor was going so horribly. All of that was true, but all of it still wouldn’t have been as bad if I had had the support I wanted….. Anyway, sometime after lunch your dad and I kicked his mom out of the room so we could talk about whether I should get an epidural. We decided that since I couldn’t get out of bed or change positions to try to deal with the pain and help the labor along, it didn’t make sense for me to be in so much pain. The next time the nurse came in, I asked for the consent form, and after going to the bathroom one last time I signed it. After that, my contractions intensified again. I was still crying, and now I started puking my guts out, too. God, it was horrible. Mom and Tomas held the stupid kidney bowls for me, and I fruitlessly clutched the side rails of the bed, trying so hard not to lose the last little bit of control I had over myself. Oh, how I hated it. The anesthesiologist finally got to me, and your dad held me as the needle went into my back. Within minutes, there was no more pain and I felt like a different person. As much as I had wanted to avoid the epidural, I was so glad to have it. Your heart rate was still dropping, though, and now I had developed a fever, too. We had internal monitors, IV antibiotics, constant checks, catheter…. Pretty near every possible intervention. And still, I was no closer to giving birth.

It has been almost 8 years since I failed to finish Vince’s birth story, and in many ways I have forgotten how painful the experience was. Over the course of the night, my labor complications continued. Though I was at least somewhat able to rest after getting the epidural, my fever continued to be nonresponsive, Vince’s heart rate continued to be problematic, and I never dilated fully. After reaching a point where there was “just a lip” of cervix left, I swelled back down to 9 cm and at that point my OB said we should go in for a c-section. Vince was born at quarter to three on Saturday morning, big and healthy. I remember hearing his first cry, and crying myself. After the c-section, I spent the better part of a year unable to forgive myself for “failing” at labor and delivery.

Thursday, July 29, 2010

Are all cesareans necessary?

In a blog titled "The Myth of The Unnecessary Cesarean" Dr. Nicholoas Fogelson argues that while many cesareans may be preventable, it is impossible to truly call any specific c-section "unnecessary" because we don't know what would have happened had the surgery not been performed. There's some excellent discussion in the comments (and I can't tell you how great it was to see the doctor coming back and responding!), I posted the topic for discussion on BabyCenter's VBAC board, and the discussion has continued on other blogs as well. As you might imagine, many who feel strongly about the cesarean epidemic are taking Dr. Fogelson to task, saying he's missing the point and sometimes suggesting he is no different from any other scalpel-happy OB.

I beg to differ.

Don't get me wrong. I understand the necessity of questioning the reasons behind an unwanted cesarean. I understand needing to look back and find failure in the system that put you in the OR rather than finding failure in your body. I spent literally years trying to pin down how I really felt about my own c-section, and after almost 8 years I still have not been able to finish writing my birth story because by the time I've read what I do have written I'm an emotional wreck and just can't face it. And yet... when I read the responses to Dr. Fogelson's article, what strikes me is the defensiveness, the aggressiveness, the instinct to attack over a single turn of phrase rather than consider that perhaps we are trying to acheive the same goal with different words.

Words are powerful, and the way we talk about birth is important. I've been taken to task for using the word "normal" in my blog title, we talk about how discouraging it can be when we're told we'll be "allowed" to have a "trial" of labor, and I've even seen heated debates about whether or not a cesarean should rightly be called a birth at all. While the perspective offered by this OB may raise our hackles, I think it can be helpful if we sometimes lower our defenses and agree to speak the same language when we're talking about birthing options and outcomes.

Tuesday, July 6, 2010

Mainstreaming Midwifery- are OBs the answer?

I've been reading a little bit lately about the suspension, reinstatement, and subsequent resignation of a popular SoCal OB, Dr. Biter. There's an entire group dedicated to his saga, and I really enjoyed a blog The Navelgazing Midwife wrote about the situation. I don't know enough about the details to address Dr. Biter's situation directly, but it did get me thinking about how we view the hospital experience from a patient perspective vs our expectations of our providers in the same setting. I've seen OBs like Dr. Biter referred to as "a midwife in OB's clothing" and that concept brought me back to something I've been intending to write more about: the mainstreaming of the midwifery model of care.

Here's what I want to know: When women flock to OBs who support birth as a natural physiological process, why are they doing that? I've read that OBs whose practices are similar to the way midwives practice are often incredibly overbooked and women wait hours for their appointments. I've seen and heard members of the birth community rave about Dr. So-and-So who truly supports his patients, has fabulous bedside manner, and should be at the top of everyone's list when they are looking for a provider. I've listened to other moms talk about the kind of care they wish they'd received from their OBs, and even though that care sounds an awful lot like midwifery, most women- even the lowest-risk women- absolutely believe they require an OB's care to have a safe pregnancy.

What would maternity care look like if low-risk women were directed to midwifery care instead of being shoehorned into the only "good" OB practice available? What if those OBs worked with large midwifery groups, where low-risk women received care from midwives, secure in the knowledge that they'd have an incredible OB backing them up if they did become high-risk? What would it take to see true partnership between OBs and midwives in the US- similar to what seems to be the norm in many other countries? I understand that the relationship between obstetrics and midwifery in the US is complex (to say the least), but there clearly are OBs who are willing to buck the system. Could they be the answer to increasing midwifery care for low-risk women? Or is it unrealistic to expect any OB to tell a woman she's low-risk and doesn't need obstetric care for her pregnancy?

I don't have the answers to these questions but they are asked honestly. Women seem to want the kind of care midwives offer, but they want that care from an OB. Up next in my musings: why don't midwives have the kind of instinctive trust and respect we give OBs?

Sunday, June 13, 2010

Kegels, Fat Obstetrics, and Fear Factor

I just realized I haven't posted here in almost a month. A MONTH!! I've been diligently working on a post continuing my "mainstraming midwifery" thought process but I keep getting sidetracked. So, a couple random thoughts on recent things I've read:

Are you going to stop doing your Kegels? Apparently the concept that kegels don't work has been around for a while- a quick Google search turned up all kinds of information on how unnecessary and ineffective they are. I wonder, though, if we're tossing the baby with the bathwater? Even if Kegels are not the whole answer, comments I've seen are generally in the vein of "Great! I didn't like them anyway and now I can stop doing them!" Is doing nothing really going to be better than doing something? I'm not a physiologist. I don't know much at all about exercise and muscle-building, but I do know everything I've read about getting in shape suggests that balance is critical. I also believe that Kegels helped me personally, though I never did hundreds a day and I was doing a lot more than just Kegels. I'm going to be watching to see if any more information comes out about this, and in the meantime, I'll keep Kegeling like I always have.

The Navelgazing Midwife wrote a great blog about Fat Obstetrics. I was clinically obese prior to (and during) my first pregnancy, and no one ever said a word about the potential impact it had on complications. Even outside of pregnancy, I had only one care provider tell me my weight might be affecting me negatively. That was a company RN who was doing my annual physical; she told me my high blood pressure (consistently in the 140/90 range) could be due to my weight, and that if I made some simple changes (she suggested walking a mile a day) I could see big improvements in my health. I blew her off- my labs were fine, high blood pressure ran in my family, and I was healthy. Well, except for my recurrent rectal abscesses, which are typically seen in obese middle-aged men, but my doctor said that's just one of those things that happens. Nothing I could do about it, except get through my pregnancy and then have surgery to correct it. After my pregnancy, I decided to make a concerted effort to lose weight, and over the course of 7 years I lost about 50 pounds. I'm (barely) in normal weight range, my blood pressure is normal, and I never did have to have surgery for an abscess because they never came back. Okay, okay, I know anecdotes aren't that statistically useful, but I can tell you that I went from "healthy" to seeing big improvements in my health. I don't judge women who are still struggling with weight because I know it is a struggle, but I don't like the message that we're all medically the same regardless of our weight. Big women deserve respectful, quality care-- but quality care has to include an honest discussion about the impact our weight can have on our health even if we appear healthy. I think Barbara really nailed the issue in her post, and I highly recommend reading it!

Where does Fear Factor come in? Everywhere. I feel like everything I've read lately has been based on Fear. Fear of offending, fear of intervention, fear of losing control, fear of having too much control, fear of failure. Is it possible that we, collectively, are trying to circumvent the necessary processes of overcoming our fears? We seem to look for an easy answer- no more Kegels! Fat is Healthy!- wanting to find utopia without having to slog through the messy realities of change. And this brings me back to the post I'm trying to write about midwifery care and whether or not it's realistic for an OB who supports physiologic birth to work in a hospital setting. That will be coming soon!

Tuesday, May 25, 2010

Shouldn't it be about more than just pushing out a baby?

I'm not going to link to the birth stories I'm about to discuss because I want to respect the feelings of these moms. They are happy because they achieved something that seemed impossible: they VBACed! They VBACed against the odds- with an unsupportive doctor, or after being told they had to induce to avoid a big baby. They VBACed triumphantly: a big fat I-told-you-so to the establishment that told them they couldn't. They should be on a good strong high for a good long time- they deserve it, they DID IT, they proved they are capable.

And yet, my heart wrenches reading their stories. A woman told she had to induce because her baby was getting too big, a doctor who cuts an episiotomy that extends into a 3rd degree tear and significant internal damage, a mom whose blood pressure crashes and who passes out due to blood loss. Another woman with an unsupportive OB who tells her she better push her baby out in 10 minutes or she'll be cut open again- amazingly, mom is able to do it, but not without sustaining a 3rd-degree laceration in the process. Someone else whose epidural dose is upped right before she starts pushing, another 3rd degree tear.

Reading all these stories so recently, a part of me wonders if this is really better than the alternative RCS. Are OBs punishing women who choose VBAC, women who "force" the doctors to be on the L&D floor waiting for them to deliver, who increase the potential for a malpractice suit? Is there a subconscious bias encouraging OBs to think "She wanted to VBAC a huge baby, this is what she gets" as the scissors slice through the mother's perineum? (by the way, that baby was barely over 8 pounds...) Or, even scarier, is there a conscious thought process on the OB's part: "I told this woman I don't like vaginal births, period, so if she can't push this baby out in the time it would take me to get the OR prepped, I'm cutting her."

Or were these OBs going to be awful no matter what? Are these the OBs who talk about their dinner plans while performing RCS, completely forgetting that the mother and father are there for the birth of their baby? Would these doctors have asked the mothers to get their tubes tied as they were lying there on the operating table? Would they have lied, telling the mothers they were moments away from rupture, so they could add to their own perception of themselves as saviors?

Though I will never regret encouraging women to choose VBAC and pursue it even when the odds are stacked against them, my heart aches because the women whose stories I've read this week deserved so much more. They deserved support, respect, encouragement, so much more than the simple triumph of pushing their babies out. A long time ago I read a line about how our goal in promoting VBAC needs to be more than simply having babies come out of vaginas. These birth stories really brought that home for me, and made me realize once again the scope of what birth activists are up against.

Saturday, May 15, 2010

Prove me wrong!

Over the past few years, I've been trying to track down a source for a statistic that I am fairly sure doesn't exist. More and more frequently I am hearing from women who've been told the risk of uterine rupture in VBAC is the same as the risk of uterine rupture for a first-time mom, or for an induced first-time mom.

Listen, I am all about putting the risk of rupture into perspective, but just as I hate it when the risks of cesareans are understated or misrepresented, I can't tolerate the same thing from my own camp. Every single source I have been able to find shows rupture risk in VBAC many times higher than risk with an unscarred uterus, regardless of parity, induction of labor, etc. I can not find a single reference in literature to a study showing a 1/2% to 1% risk of rupture in a non-VBAC labor. All I find are dead ends, and data confirming that a uterine scar is the single biggest risk factor for rupture.

I've asked multiple people in multiple forums for a source substantiating this claim, and no one has ever been able to provide one. So I figured I'd ask here too: does anyone have a source that will prove me wrong?

Tuesday, May 11, 2010

Happy birthday to me!

About this time 37 years ago my mom was in labor with me. It was a Friday, and I was 10 days "late." Nobody had talked to her about induction, or how big I was going to be, or how dangerous it was to be pregnant for so long. Awesome, right? She was also required to have an epidural, be shaved, and have an episiotomy. Not so awesome.

I think it's interesting to contrast my own birth experiences with my mom's. So many things are better today, but many things are worse as well. Even as we have demanded- and to a certain extent received- the right to make our own decisions in the delivery room, we have stopped viewing pregnancy and birth as a normal and natural part of a woman's life.

Hopefully when my daughter is having her children, she'll get the best of both worlds.

Thursday, May 6, 2010

When natural birth doesn't come with a glow

Some people run marathons, others climb mountains. My personal challenge was natural childbirth. I wanted to deliver my baby spontaneously, with no drugs, and with minimal intervention. Having my first birth end up in the OR following virtually every intervention known to womankind only strengthened my resolve to have my next child "the way nature intended."

And I did. Spontaneous labor, no drugs, very little intervention. I arrived at the hospital 4 cm dilated and delivered an hour and a half later. I still laugh to myself remembering the nurse freaking out about not having an IUPC in place, and the OB telling her "I'm pretty sure she can tell us when she's having a contraction." It was surreal to realize the nurse was still watching the monitor, waiting to "see" a contraction that I was already pushing through. And push I did- after only 15 minutes my son flew into the world, hale and hearty. This was my moment, victorious, triumphant. I had done what I set out to do, crossed the finish line, reached the summit. It was amazing.

And almost immediately afterward, it was terrible. I fully expected to feel amazing after my birth. I was going to have my baby in my arms, nursing contentedly, while I lay in the afterglow of having just given birth. I was going to feel strong, sure, empowered. But I didn't. I had torn significantly and it took longer for those repairs than it had for my c-section closure. I didn't get to hold or nurse my baby for over 4 hours due to concerns over possible meconium aspiration. The first time I got out of bed I passed out cold. And when my nurse asked how I felt, I replied without missing a beat: "I feel like I was just raped by King Kong." Afterglow? Hardly. Where the hell was the experience I'd been promised by all the natural childbirth advocates? Why didn't I feel amazing? If this had been Everest I would have reached the summit only to vomit all over myself and pass out from lack of oxygen before enjoying the view. If this had been a marathon I would've crossed the finish line and been rushed to the hospital for heatstroke before I heard the first "congratulations!" It certainly wasn't what I expected.

I went on to have 2 more babies, and while I still completely believe that birth is a normal event in a woman's life, and drug-free low-intervention delivery is the best and safest thing, I had epidurals with both of them. I spend a lot of time justifying this to myself because I am such a strong advocate of natural childbirth. I also spend a lot of time wondering if I'm really being fair to other women when I advocate natural birth without talking about how my own experience was so far from what I expected- so there you have it. Full disclosure.

Friday, April 30, 2010

Does VBAC kill babies?

A couple weeks ago, I read a comment from an OB who said if his practice supported VBAC, he and his partners could each expect to have 1 "preventable" neonatal death following a uterine rupture. He asked if that was acceptable. On Dr. Amy's blog, she says that no one in the advocacy community addresses the issue of the "excess" deaths caused by VBAC. And then the NIH released information showing the neonatal death rate for VBAC was over twice as high as the rate for repeat c-section. There is ample evidence that more babies will die during VBACs than during repeat cesareans- so why should VBAC be a valid option?

First and foremost, I want to make it clear that I'm not in favor of anyone losing her baby. I simply can not imagine the grief, the pain, the countless ways someone's life would be forever changed by that kind of loss. I don't expect any woman to "take one for the team" by losing her baby during a VBAC attempt; I absolutely do not believe in vaginal birth at all costs. What I want to address here is whether or not the greater risk of neonatal death during VBACs should affect policy-level decision-making and support for VBACing moms.

After thinking about it for a couple weeks, my simple answer is no. I see a huge logical problem in arguing that VBACs should be banned (or that OBs have a legtimate right to refuse to support VBAC moms) due to the increased risk of neonatal death. While the NIH statement does show that more babies die during VBACs, they go on to say that the risk is virtually the same as it is for any first-time mom. This made me wonder, why isn't the "dead baby card" pulled out for first-time moms? Why are they not counseled to schedule their c-sections at 38 or 39 weeks so their babies won't die? If everyone can have a c-section and the noeonatal mortality rate could be cut by 60% or so, why NOT tell everyone she should deliver that way? There must be inherent benefits to vaginal delivery, and those benefits must be great enough that they outweigh the increased risk of neonatal mortality.

So why do the inherent benefits of vaginal delivery not seem to affect VBAC policy? Two words: malpractice liability. It is expected and accepted that a certain number of primiparas will lose their babies to late-term stillbirth or complications of childbirth, and those cases will (generally) not result in enormous lawsuits. One baby lost to uterine rupture, though, could destroy the livelihood of even the best OB. I've seen it said over and over: Would you risk everything to support a woman's VBAC? Would you risk your career, your savings, your family's financial security? Would you really?

The biggest problem I see is the lack of transparency and honesty in the discussion. When OBs focus on "preventable" deaths and yet don't require ALL of their mothers to schedule cesareans, it's clear that the issue isn't just preventable deaths. When others rail at advocates for not addressing "excess" deaths but don't talk about why it is only VBAC deaths that matter, they are completely missing the point the advocates are making. When we as advocates direct our ire toward providers who really are between a rock and a hard place-- you know, we're all spending so much time being pissed off and defensive that we're just not getting anywhere.

I think the NIH conference was a great start in clearing the air between activists, providers, and VBAC moms. I hope to see the issue of "excess" deaths in VBAC continue to be put in perspective on a policy level (as it was in the NIH statement), so that women can have access to complete and accurately portrayed information as they decide how to deliver their babies.

Monday, April 26, 2010

Choosing an experience: My journey to VBAC

Check out my latest blog over at Andrea Owen's site:

It has always troubled me that VBAC moms are criticized for choosing a "birth experience." Frankly, women who choose RCS are choosing an experience, too, albeit a very different one. I know there are a million reasons women choose RCS, I know OBs offer scare tactics, I know women who've been "fired" as patients when they refuse to schedule a cesarean. Some women truly don't have a choice, but others- most of us- do. It used to make me incredibly uncomfortable to say I wanted to VBAC because I wanted to experience vaginal birth. I felt like I had to justify my decision, defend it and prove that I wasn't some crazy VBAC lady who would sacrifice her baby in the name of a vaginal birth. That was never the point, after all. The point was being a healthy mom, delivering a healthy baby, by way of my vagina. As the weight of evidence continues to build, and VBAC continues to be shown as safe as, if not safer than, RCS, I hope more women become comfortable speaking about the experience of vaginal birth. We won't all value it the same, obviously, but those of us who do place great value on it shouldn't be afraid to talk about it!

And so I'll say it, one more time, for posterity:

The single biggest reason I wanted a VBAC was because I wanted to experience a vaginal birth.

Now go visit Andrea's wonderful blog and read the whole post! :-)

Sunday, April 25, 2010

My relentless pursuit of perfectionism

I started this blog with the best of intentions. I wanted a forum where I could drop some of my usual diplomacy and really talk about the things that matter to me in the birth world. I wanted a place to develop my voice as an activist, where I could learn about myself as I continued to define and refine my thoughts about modern maternity care. In short, I wanted a place where I could say "HEY YOU GUYS! DID YOU SEE THIS?!?!" and give my untempered opinion.

But I ended up not doing much of that, and instead spent who-knows-how-long fact-checking and finding statistics to back up my opinions and making doubly sure that everything I posted was accurate, accurate, accurate. And that was useful (I guess, but damn, itt wasn't as much fun as I thought it would be!!

So a new direction: I will start posting more. I won't try to achieve perfection before I hit "publish post." I will be gracious and willing to accept it when commentors challenge my beliefs, but I won't spend so much time worrying about diplomacy. I will find my voice- my true voice- and, hopefully, that voice will be one people enjoy hearing.

Monday, April 12, 2010

Read my latest blog post

My friend Andrea Owen asked me to guest blog for her in honor of Cesarean Awareness Month! Read my post "Caveat Emptor: The Real Risks of Cesaean Section" here:


Thursday, March 11, 2010

Slacktivist? Not me!

Sometimes I feel like a big fat hypocrite. I rail against the status quo of modern obstetric care, and yet all I really do to "change" things is sit here behind my keyboard and wait for women to find me on BabyCenter's VBAC board so I can encourage them to take charge of their births and make informed decisions. Am I really helping? Or am I just another slacktivist, wanting to feel like I'm involved but in actuality staying far removed from promoting actual change?

Over and over I have told women that we need to keep talking about our births and if we reach just one woman we are making a difference. Every time someone reads our posts, every time we talk to someone about our VBACs, every time we tell someone she has options, we are making a difference. I do believe this kind of ground-level advocacy is important. There is no question that individual women need support in making non-mainstream birth decisions! And yet I long for something more, something that sparks change in the system so that women are actually served by it instead of failed by it. This feeling has been so strong lately that I've been considering taking a break from all of it, turning over group ownership of the BabyCenter board to someone else, just letting all of it go. I don't have the time or motivation to be as involved as I think I should be, and this small part... oh, I just don't know.

But two things happened this week. First, Kristen from www.birthingbeautifulideas.com reminded me how critical mother-to-mother support was in her own VBAC journey. And then this morning I decided not to stay quiet when I overheard a young mother talking about how her OB told her she had to have a repeat cesarean, and that she would have to limit herself to three children because it wasn't safe to have more than three cesareans. It has never been in my comfort zone to sepak up in situations like that, but listening to this young woman talk about how her reproductive life was going to be defined by her first cesarean... it made me so angry! Exactly who does her OB think he is, to tell her how many children she can have and how she has to deliver them? She said she wants to try to deliver vaginally, but was flat-out told she can't.

When I spoke up this morning and told the entire group that my first baby was born by c-section but my other three were born vaginally, and offered to share resources and information, I made a difference no matter how small. Sure, I felt like I was being pushy and intrusive and I totally blew the pretense that I wasn't eavesdropping-- but maybe I opened a door to allow this young woman to regain control of her reproductive future. I will probably never be the kind of activist Kristen has become (and I can't say enough about how much I admire her), but maybe being a ground-level advocate really is the thing I'm supposed to be doing. I'm pretty good at it, I think. And today I might just have reached one woman.

Friday, February 19, 2010

Shifting the paradigm: VBAC should become the norm

For years I have believed that once a woman has a cesarean, the choice to deliver vaginally (VBAC) or have another c-section (RCS) for future deliveries should be entirely hers. I've believed that the risks, while different, carry roughly equivalent chances of worst-case outcomes. It is up to each of us to determine which set of risks we are most comfortable with, and go forward making the decision that will allow us to look back without regret. I have struggled to learn to support women who looked at all the evidence and still chose RCS- it is definitely not a choice I would not personally make- but in the end it was never my place to judge someone for making the decisions that she felt were right for her and her baby.

While I still don't feel I have any right to judge women who choose RCS, I have reached a point where I don't feel that is at odds with speaking up for VBAC. I recently read that over 50% of women would like to attempt VBAC, but nationally less than 10% actually do. Why is that? I'm sure there are a certain number of women for whom VBAC is legitimately not an option, but the majority are probably very good candidates and yet they choose (or are forced to choose) RCS. Why?

VBAC is vilified, there's no doubt of that. Lawyers like this Indiana Medical Malpractice Lawyer are all too willing to support the perception that VBAC is in and of itself a needlessly risky procedure that often results in poor outcomes for mothers and babies. There is a pervasive belief among the general public- and among juries- that a c-section represents everything possible being done to ensure a healthy and safe delivery, and I've often seen it said that OB's are never sued for the c-sections they perform, only the ones they don't.

But I don't really want to talk about medical malpractice, I want to talk about why major abdominal surgery is considered the normal way for a baby to be born, just because his mom has a scarred uterus. Recent studies are coming down in favor of VBAC as safer than RCS for moms and babies, and it is absolutely clear that RCS increases future risks for women and their subsequent babies- but even if the risks were equal, why do we believe the intervention is better than the natural process? Why are we burdening our healthcare system with the time and expense of so many cesarean sections when there is an equally safe (possibly safer) and much less invasive alternative?

It is time for this paradigm to shift. I'm not suggesting that the option of repeat cesarean be taken away, but I believe we need to change the starting point when a woman is choosing between VBAC and RCS. In today's obstetric world, RCS is the automatic assumption and women who don't have a compelling reason to attempt VBAC rarely do. It is even more rare for an OB to encourage a woman to choose VBAC. This is completely upside down! We shouldn't have to fight and change doctors and travel for hours to be "allowed" to labor and deliver our babies without being cut open. We should expect to deliver vaginally unless there is a compelling reason to do otherwise, and VBAC should be the first option offered to women with a previous cesarean.

A shift in our thinking, a return to normalzing birth... I'm not idealistic enough to think it would be easy, but I am not cynical enough to think it's impossible either. I still have hope that one day in the future, the 50+% of women who would like to have a VBAC will be supported and encouraged.

Thursday, February 11, 2010

The Gentle Cesarean

For years now I've been a part of the VBAC support forum on BabyCenter, and I've read literally hundreds of women's cesarean birth stories. I've read some positive and empowering stories, and I've read some tragic ones that truly fit the term "birthrape." But I have never read one like the one Joanna Moorhead describes in this UK article titled "Every Bit as Magical." Professor Nick Fisk is pioneering a cesarean technique he calls the "skin-to-skin cesarean," a significant improvement over the clinical and reserved deliveries most c-section moms expect.

Picture this: Instead of being literally strapped to the table with her view obscured by a curtain, the mother is propped up so she can see her baby's birth. Instead of the surgery being performed as quickly as possible, the pace is slower, gentler. Instead of the baby being whisked away, he is immediately placed on his mother's chest. The cesarean is recognized and honored as what it is- this baby's birth- instead of being performed like just another surgery. How wonderful would this be for women who have to have cesareans?

Taking it a step further, how wonderful would it be if all mothers could expect to be treated like their births are amazing, magical, worthy of respect and consideration? No matter how our babies enter the world, birth remains one of the most powerful and unforgettable experiences we will ever have.

Sunday, February 7, 2010

Elective cesarean: The new media darling

In case you missed it, the Today Show televised a cesarean birth. A CBS affiliate in New York is publicizing a "Growing Trend: Expectant Women Schedule C-sections." Obstetric texts are compiled to show the benefits of cesarean delivery, and then those texts are quoted and debated by women who believe cesarean delivery may truly be the best and safest way to deliver babies. Every time I see these glowing portrayals of surgical births, it makes me a little bit sad, more than a little bit frustrated, and even more it makes me angry.

I am angry that we are building a culture perceiving cesarean birth as a low-risk procedure that is safe for babies and not a big deal for mothers. I am angry that women perceive vaginal birth as something to be avoided at all costs, and I am angry at the obstetric community for doing so little to allow women the opportunity to birth in a way that is neither physically nor emotionally traumatic. I am angry because women are making birth decisions based on fear, and I'm angry because the mainstream media buys into and feeds that fear. "Don't worry, honey, you don't have to go through anything terrible to have your baby- watch this video, see how easy the c-section is? The baby is out and safe and they chose the right way to deliver. Next week: brain surgery!" What else can we trivialize?

The reality is that elective cesareans have risks, for moms and for babies. Surgical delivery is not a peaceful, gentle birth any more than vaginal delivery is a hellish squeeze through the maternal pelvis. There are grains of truth in the stereotypes, but there is also a reason birth has evolved as it has. Labor is good for babies, the squeeze through the pelvis designed to clear the lungs of amniotic fluid. There is a reason for birth, and more of us need to speak up about it. Cesarean birth is not the same, it is not safer, it is not risk-free and it is not "no big deal."

I can hear the criticism already- this post is unsupportive, I am judging mothers who have to have cesareans, I'm ignoring the fact that cesareans have saved countless women and babies. First, I'm not talking about medically necessary cesareans because clearly there are times that the risk of cesarean delivery is far less than the alternative. My purpose is also not to judge women who have made informed decisions to have elective cesareans. We absolutely need to support women in making informed choices, and that includes women who choose repeat cesareans or even primary elective cesareans. That does not mean I think we should stand silently by while a woman has a primary c-section at 38 weeks for a suspected big baby after being told horror stories about shoulder dystocia by her OB. That does not mean we have to listen quietly while someone says her c-section is better for her baby because her baby won't have to squeeze through the birth canal. That does not mean we should remain silent about the fact that pelvic floor damage is caused more often by pregnancy itself than vaginal delivery- and when it is caused by vaginal delivery it is often associated with highly interventive births, directed pushing, episiotomy. Supporting a woman in making decisions about her birth should be more than simply smiling and nodding and ignoring the stench of the bullshit that is thrown around like fact when it comes to birth.

I think it is entirely possible for women to be fully informed and educated and smart, and still value a different birth experience than I do. I can use myself as a prime example- I 100% believe that natural childbirth (the unmedicated, low-to-no-intervention kind, not just vaginal birth) is the absolute safest way to bring babies into the world. I 100% believe that for low-risk women, intervention is largely unnecessary and often adds needless risk to birth. However, I still chose epidurals with my last 2 VBACs, I still scheduled a medical induction for #3 (didn't make it that far, but I fully intended to induce if I had). After evaluating my options and researching my decisions, the benefits of those procedures outweighed the risks. Anyone else might have done the same research and made a different decision- and I would have fully supported them.

What I do not support, and what I judge, is a woman who deliberately chooses to make an uninformed decision and expects me to sing the praises of her choice. "All that matters is a healthy baby" has become the mantra, yet women are conditioned to believe intervention always equates to better outcomes, and our nation's morbidity and mortality statistics simply do not back that up. We need a big wakeup call, not just "support" that amounts to encouraging ever more uninformed decisions and greater social acceptance of high-intervention deliveries and elective cesareans as the norm. We need the media to stop glorifying elective cesarean and portraying vaginal birth as torturous hell. We need to find a way to have normal birth get the glory that's reserved for surgical delivery today. We need the mainstream media to tell women their options are not limited to either the overmedicalized horror show that passes for birth in many hospitals, or an elective cesearan.

If we don't start demanding change, the trend toward primary elective cesarean will continue. If we don't let media outlets know how unhappy we are with the way they misrepresent the realities of birth, they will continue to support and encourage us to view cesarean birth as the easy, no-muss-no-fuss way to deliver our babies. We deserve better.

Saturday, January 30, 2010

Is VBAC high-risk?

If I've heard it once, I've heard it a thousand times:

"My OB says VBAC is too risky and I should just have another c-section"
"Why would you risk your baby's life just so you can have a birth experience?"
"I'm having a repeat c-section because the most important thing is a healthy baby"

It wasn't that long ago that once you had a c-section, all your babies would be born that way. "Once a c-section, always a c-section" was the rule, and it was arguably a good one since cesareans were performed using a classic, up-and-down incision that extended well into the contracting portion of the uterus. That type of incision has a greater risk of rupturing during subsequent labors than the low-transverse incisions typically used today. With the risk of uterine rupture following a low-transverse c-section right around one-half of one percent, vaginal birth after cesarean (VBAC) has become a real option for women hoping to avoid future cesarean deliveries. And yet, controversy still surrounds the safety of VBAC vs. choosing repeat cesarean (RCS).

What is without question is that any pregnancy following a cesarean delivery carries significantly greater risk than a pregnancy in an unscarred uterus. Among those risks are higher incidence of placenta problems including previa, accreta, and abruption; higher risk of unexplained stillbirth; greater risk of preterm labor; and not least, uterine rupture. While we most often associate uterine rupture with a VBAC trial of labor, the reality is that even prior to labor, a woman with a previous cesearean delivery has a risk of rupture twelve times greater than a woman with an unscarred uterus having a normal vaginal delivery. The risk is still incredibly small- about 0.2% prelabor rupture for women choosing RCS, 0.4% rupture in a spontaneous VBAC, somewhat higher for induced or augmented VBACs- but without that scar, the risk is only 0.013%. Whenever we talk about delivery options for pregnancies after cesarean, I think it is important to recognize that we're not comparing VBAC (or RCS) to an uncomplicated vaginal delivery. We're comparing the available options, which are VBAC and RCS, and neither option is risk-free for moms or for babies.

Risk assessment is a personal thing and it's not surprising that when we are making decisions about something vitally important- how to get our babies out of our bodies and into the world- even the smallest risks can seem enormous. When we are pregnant the first time, it's just assumed we'll deliver vaginally. Once we have the option of delivering by VBAC or RCS, once we have to choose between risks, once we are forced to decide which set of horrific outcomes we prefer to chance- well, the decision isn't always an easy one. It's made even more complicated when women who want to choose VBAC are told that it's high-risk, or it's implied that they are selfishly pursuing an "experience" at the expense of their babies' health. OBs have endless "requirements" for VBAC moms due to the perception that it is risky- limits on gestation, limits on baby's size, "requiring" epidurals, requiring induction to ensure the hospital is fully staffed, requiring VBAC moms to deliver in the OR rather than an LDR room, continuous monitoring, internal monitoring, no laboring at home... you would think a VBAC mom's uterus is a bomb waiting to explode!! But is VBAC really high-risk?

The first thing I consider is how non-VBAC, vaginally birthing moms are treated. The potential for a complication requiring a truly emergency cesarean is there in any vaginal birth! Cord prolapse and abruption occur in .18% and .4% of labors respectively but those risks are not perceived as great enough to make all laboring mothers "high risk." In a VBAC labor, adding uterine rupture to prolapse and abruption, the risk of needing a truly emergent delivery is raised from about .6% to just under 1%. Does that increase justify a high risk designation?

And what about uterine rupture? Are the consequences of rupture so severe that even a small risk of rupture makes VBAC high-risk? While somewhere between 0.4% and 0.7% of VBAC labors will result in uterine rupture- a complete breach of the uterine wall- it's important to note that even a complete rupture is not always 'catastrophic' in the way that term implies. Less than 10% of complete ruptures result in permanent damage to mother or baby. 1 in 2,000 babies will suffer brain damage or death following u/r in a VBAC attempt. Is that "high risk?" If your answer is yes, would you change your mind if I told you that 1 in 2,500 mothers will die after choosing RCS?

Identifying a rupture when it occurs should be part of the equation, and the only sign that consistently occurs in the majority (but not all) of ruptures is a prolonged period of decelerations in fetal heartrate or bradycardia. This is also a sign of fetal distress in non-VBAC labors, and seems to be identified and responded to well in both hospital and non-hospital birth settings even without use of intervention like continuous monitoring or internal monitoring. Is that high risk?

What about outcomes? Recent studies are showing that women who choose VBAC have better outcomes overall than women who choose RCS. That's not comparing successful VBACs to RCSs either, it's comparing intended VBACs, whatever the outcome, with scheduled repeat c-section. Less NICU time, less respiratory morbidity, and less time in the hospital. Three times lower rates of infant death in the first month of life. Lower maternal morbidity and mortality. And that doesn't even begin to consider the impact of this birth on future pregnancies, an area where VBAC has clear advantages. High risk?

The additional risk of a cesarean scar follows a woman throughout her reproductive life and adds risk to all her future pregnancies. Uterine rupture is a real risk that is quite dramatically increased with a previous cesarean regardless of how a woman opts to deliver her future children. Women are absolutely entitled to do their own risk assessment and if they desire a more cautious approach to monitoring, both during pregnancy and during labor, they should be able to have that. However, given the increased risk of rupture even prior to labor's onset (which no one worries about), the better outcomes provided by VBAC, and the fact that providers should be ready for an emergent situation even in non-VBAC deliveries and those emergent situations occur with at least the same frequency as u/r, I don't think VBAC in and of itself should be labeled "high-risk."

(For further reading:

Friday, January 22, 2010

7 years later, it still hurts

This morning I read this blog http://omgdgms.com/2009/11/10/chop-shop/ and instantly, I was transported back to my first birth. The induction I "had" to have, the utter lack of informed consent, the complications that I now realize are incredibly common during inductions, the interventions I know I should have refused, the monitoring I should have asked for before agreeing to be induced at all. I hadn't read my birth story in a long time; I much prefer the more positive version I choose to think of to the written version I never finished. Because what happened in reality was not what my birth was supposed to have been- a few lines from my birth story:

Labor! I thought.

and both of them came into the labor room-- this was after I had said I didn't want anyone in the room except my husband and my mom

when I got back to the room we had to start pitocin

I had to be hooked up to monitors all the time

then the downward spiral began

I was stuck in bed, I couldn't do anything for myself

I was tired and scared and frustrated and hurting, and I felt alone

I found myself thinking, "Good lord, could you just keep everybody the fuck out of here???"

she and the nurses kept asking me why I was crying. I couldn't tell them

I asked for the (epidural) consent form and after going to the bathroom one last time I signed it

now I started puking my guts out too. God, it was horrible.

Oh, how I hated it.

We had internal monitors, IV antibiotics, constant checks, catheter... Pretty near every possible intervention. And still, I was no closer to giving birth.

That's where I stopped writing. After I got the epidural I was no longer in pain and I stopped vomiting, but the rest of my labor complications continued. The hours continued to pass and I have to give some credit to my OB- I asked for a c-section long before she agreed it was time to perform one, and Vince was born just before 3 a.m. so I certainly can't say it was a matter of convenience for anyone. But the induction, the labor, were so awful... I felt like I'd been completely abandonded and my wishes didn't matter at all, to anyone. At one point I locked myself in the bathroom, I just wanted to escape it all, have the chance to labor and birth my baby in peace. But I didn't get that chance.

It has been so long since my son was born that I am caught off guard when I realize how emotional I still am about it. I used to feel like a failure but I don't any more. Now I just feel sad, both for the woman I was and for every other woman who has to go through an experience like mine. When did it become okay for birth to be like this? How did we go from twilight sleep and preventative forceps deliveries to this? Is inducing and medicating and offering technology instead of comfort really the answer to a better, safer birth? We've traded one illusion of control for another, and we've convinced ourselves that we are somehow to blame when it fails. The technology is infallable, our bodies are what's broken. We failed to dilate, our babies didn't tolerate labor, we developed infection. It's not because we weren't ready for labor or pitocin-induced contractions are harder on babies or artificial rupture of membranes combined with multiple internal exams increases infection risk. No. Because those things are controllable, we are the wild cards, we are the ones who failed.

Like I said, I no longer feel like a failure. I know I am capable of giving birth, I know my faith in the process was not misplaced. I just wish I could go back in time and sit next to that woman who was me, reach out to her, hold her hand, tell her that she had options. Tell her it is okay to ask questions and even say no. And then, later, I wish I could just put my arms around her, hold her, let her cry out her perceived failures, and tell her that at some point in the future those feelings would fade, and she might even find ways to use her experiences to help other women avoid going through the same thing. I can't go back, though, and my heart aches when I remember how much it hurt to have my first birth be such a testament to the failures of modern obstetrics. It still hurts, even 7 years later.

Friday, January 15, 2010

Reducing elective induction reduces cesarean rates

I was discussing a study with my OB during one of my prenatal appointments and he said, "Just because someone says it is so, doesn't mean it is so." I sort of laughed and said "I know" because the obvious counterpoint was that just because he said it was so didn't mean it was so either. At any rate, I ran across this study this morning, and while I can't get to the full text (yet!) I am always happy to find data supporting my belief that induction is associated with cesarean delivery:


A total of 10,166 nulliparas and 9869 multiparas attempted vaginal deliveries. Elective inductions decreased significantly, from 4.3% to 0.8% in nulliparas and from 13% to 9.5% in multiparas. A longer time to delivery was seen for both nulliparas (5.2 hours) and multiparas (4 hours) with elective inductions. Unplanned primary cesarean delivery rates are significantly lower in spontaneously laboring women, compared with those induced. (emphasis mine)

This appears to be so much better than the review I discussed in earlier posts- a large enough study group to be statistically significant, and performed recently, in the US, so it may apply to actual obstetric practice as it exists today.

Monday, January 11, 2010

Mainstreaming midwifery

This isn't going to be a typical long blog post, more like a random thought:

Last night I started thinking about how I'd always longed to have my babies either at home or in a local birthcenter that offers midwifery care and waterbirth, but either didn't or couldn't for various reasons. I wholeheartedly believe midwifery should be the standard of care for low-risk women, and homebirth an option for women who desire it. And that got me thinking: what would need to change for midwifery care and homebirth to really become mainstream options in the US? How would it change the face of maternity care? Is it realistic to expect those kinds of changes? And how would the mainstreaming of midwifery change midwifery practice itself? Though I haven't completely thought through this subject yet, I realize the answers are not simple. I'll be exploring this more in future posts!

Thursday, January 7, 2010

Why Natural Birth for Normal Women?

It's easy to find information about how modern obstetric practice has failed women. Go to just about any parenting website, and you'll find loads of articles and posts about lack of informed consent, non-evidence-based care, unnecessary intervention, outright lies being told to scare and coerce women into making birth decisions they otherwise would not make. In a less dramatic way, I believe the birth community is also failing women.

While I have always strongly desired a natural, drug-free birth, I used to be an OB believer. When I got pregnant with my first child, I dutifully went to my OB, kept all of my appointments, did everything I was supposed to. I declined induction on my due date, but when 41 weeks came and my OB said I "had" to be induced, I didn't question it. Likewise, I didn't question any of the procedures that were performed in the hospital. It was only after my c-section that I really started to learn about normal childbirth, and it was only as I planned my first VBAC that I realized how much modern obstetrics is designed to keep us in fear and make us feel like WE have failed, when in fact we were never truly given a chance to succeed. I needed an alternative, but instead of finding myself drawn further into the birth community, I've found myself deeply conflicted.

It took me a good deal of time to realize that even though my beliefs about birth were not supported by modern obstetric practice, I wasn't really far enough from the mainstream to be fully embraced by the birth community. I'm not anti-OB, I'm not anti-hospital. I don't think women should have to choose a midwife-attended homebirth to have a good birth- and, perhaps most damningly, I don't think women who choose interventions like inductions or epidurals- or even cesarean sections- have any less right to a fully informed, positive, empowering, birth experience. By and large I think the birth community gives lip service to this issue- "of course you deserve a good birth experience, dear, but how do you ever expect to have one when you make those choices?"

When I was pregnant with my 3rd baby, I went online and asked (basically) this question: "Are we doing women a disservice when we tell them natural birth is impossible to achieve in a hospital?" It seemed to me that the birth community was telling women that they should expect to be treated terribly, they should expect to have their wishes trampled, they will be forced to cede their personal power and consent to any number of invasive and potentially dangerous interventions the minute they walk through the hospital doors. Perhaps my original question was poorly phrased, but I still wonder how that message is supposed to empower women to demand better treatment for themselves. The vast majority of women give birth in the hospital, and when the people who claim they want birth to be better for everyone tell women they are going to fail, well, what kind of message is that?

The responses I got so many years ago ranged from completely dismissive to personally offensive, but they boiled down to: "Natural birth is almost always impossible to achieve in the hospital, and telling women otherwise gives them unrealistic expectations. Women need to prepare for reality." It was defeating. I felt the birth community expected its members to fit a cookie-cutter mold, just like the obstetric community did. My own options were limited to a) the hospital or b) the hospital, and while I knew I hadn't exactly asked for support in achieving another natural birth in a hospital setting (I'd already had one with my 2nd baby), I didn't expect that there would be so little support for the idea that hospital birth doesn't have to be- and should not be- the end of a woman's hope for a natural birth.

A couple years ago I was talking with a friend about our upcoming births. She was heavily leaning toward a repeat c-section, and I was heavily leaning toward a homebirth VBAC, but somehow we managed to talk about our births without judgment or defensiveness- imagine that! I mentioned something about hoping to become a childbirth educator, but not feeling like I'd really be accepted in the birth community. She said that maybe it would be good to have someone like me in the field, and I laughed and said I would call my service "Natural Birth for Normal Women." The idea has festered all these years, and is now the inspiration for my blog. This is my small way of saying it's okay when you don't fit the mold, you still deserve to have your choices respected and your birth celebrated.

And maybe in a few more years I will worry less about whether I'd be accepted, and will pursue childbirth education after all.

(I should probably give my definition of the "birth community" for the purposes of this post. I am primarily talking about anyone who actively promote non-mainstream birthing options. Yes, that includes me. :-) I should also say that while I have always felt somewhat alienated by the birth community, I am blessed to know so many women who believe so strongly in the power of women's bodies. You know who you are- and you never fail to inspire me!)

Tuesday, January 5, 2010

Did I really just read that?

My last post was about a study showing that labor induction at 41 weeks leads to fewer cesarean deliveries than expectant managment of labor. After I posted, a friend forwarded me a link to the full text of that study (thank you Ellie!!), which you can find here http://www.annals.org/content/151/4/252.full Her first comment was, "I think if you look at the induction studies, you'll find it is not really relevant to how induction is really used in the United States." I was intrigued...

So I started reading, and while the authors do conclude that "elective induction of labor at 41 weeks of gestation and beyond is associated with a decreased risk for cesarean delivery and meconium-stained amniotic fluid" the VERY NEXT SENTENCE says "There are concerns about the translation of these findings into actual practice; thus, future studies should examine elective induction of labor in settings where most obstetric care is provided." Hmmmm... What in the world does that mean? Is this review actually providing good information to use in making decisions about induction vs expectant management, or not?

The majority of the studies in the review are rated "fair" or "poor" in quality, and the authors admit that "few (of the studies) had calculated sample sizes to determine whether the study had adequate power to address the primary study question." The largest study relevant to the primary study question was excluded from results because it was published in French and non-English-language studies were automatically excluded. Many of the studies reviewed were not from the US-- and "When we stratified the analysis by country we found that the odds of cesarean delivery were higher in women who were expectantly managed than in those with elective induction of labor in studies conducted outside the United States but were not statistically different in studies conducted in the United States."

Suddenly I was realizing that this US review, that I had seen discussed on various US websites, wasn't really saying what the summaries I'd read said it should say. Induction in the US is not like induction in other countries- just like "normal" birth in the US is not like normal birth in other countries. I was starting to feel vindicated once again in feeling that my induction had led to my c-section, and then I came across this line:

"insufficient information exists with which to draw any conclusions about the effect of elective induction specifically in nulliparous women."

Even in the studies from other countries, they are unable to say that induction is a better option than expectant management for a first-time mom, and these studies don't even begin to hold the level of detail necessary to determine the effect of induction on a first-time mom with no dilation, no effacement, a baby not engaged in her pelvis. I'll never know if I could have delivered vaginally if I'd continued to wait for labor with my first baby, but this particular study no longer makes me question my deeply held belief that spontaneous labor gives a woman the best chance possible of delivering outside the operating room.